Steps to Joining MPOG

Is your department or hospital interesting in joining MPOG? It takes a bit of effort and money to join, but in return you are able to participate in impactful large scale research projects, and innovative quality improvement programs.

To become a member of MPOG an institution must use an anesthesiology information system (AIMS). Below are the steps necessary to join MPOG:

Must occur first

Sites must fill out the MPOG Application located in our Downloads section and identify all key personnel, including the following:

Department Chair or Head of Practice: in order to be successful with MPOG implementation all sites must have departmental support.

Anesthesiology Principal Investigator (PI)*: The role must be filled by an anesthesiologists who will serve as the PI who will be the research champion for the institution. They will represent the research efforts and serve on the research publications committee to help determine the scientific validity of MPOG proposals.

Anesthesiology Quality Champion*: The position must be filled by an anesthesiologist who will serve as the quality champion. They will serve on the Quality Committee to debate items of interest, including quality measure criteria, meeting agendas, best practices, data validation, etc.

Anesthesiology IT Champion*: This must be an anesthesiologist who will assist with the technical efforts of MPOG implementation. The IT Champion will work the developers at their institution and MPOG to set up the IT infrastructure of MPOG.

IT Support: The position is the developer who has been identified by the institution who will set up the database and configure the data

Project Manager / Lead on MPOG Project: This will be the person who will be the lead contact at the member institution who will help with the MPOG implementation. They will help facilitate the project including setting up meetings and ensuring the project is on task

*The PI, Quality Champion and IT Champion can be the same individual or assigned to different individuals. We defer to the institution to determine who will be best suited for the role. Please note, all of these roles must be identified.

Step 2: Obtain a Business Associate Agreement (BAA)

Must occur prior to starting step 7

A BAA is required for all institutions. The BAA will need to be in place early in the process before a site can start the technical implementation. The reason MPOG requires a BAA is because part of doing QA work MPOG will need to view PHI at sites to ensure data accuracy and quality. The BAA is required to protect both institutions from PHI disclosure during the normal course of training. The University of Michigan has a BAA template that is located in our Downloads section. Since the hospital participating with MPOG will be considered the covering entity, MPOG is required to use the hospitals BAA template.

Step 3: Complete Data Use Agreement (DUA)

Can occur concurrently with steps 1 - 7, but must be completed prior to Step 8

The DUA is a contractual document used for the transfer of data that has been developed by nonprofit, government or private industry, where the data is nonpublic or is otherwise subject to some restrictions on its use. The DUA will need to be in place before you transfer data to MPOG, Step 8. The data transfer is the last step in the technical implementation, therefore, the DUA can be completed as you are working on the technical aspects of MPOG. The DUA will need to be vetted through your legal / contract office and the DUA Template is located in the Downloads section of the website.

Step 4: Submit IRB Application to Local IRB

Can occur concurrently with Steps 1 - 8, required for a site to be active

There are two IRB approvals required to conduct MPOG research. The first is a centralized 'umbrella' IRB that enables the collection of a limited clinical dataset (date of service is included) frm the multiple institutions. This IRB establishes the University of Michigan as the coordinating center. This allows research queries of that database to be conducted on these limited dataset. This IRB does NOT need to be reproduced or established at each contributing center. As additional centers or data types are added to the MPOG effort, this centralized "umbrella" IRB will require incremental addenda.

Second, each institution (including the coordinating center) will be required to receive approval from their own IRB to send their institution's limited clinical dataset to the MPOG repository. This is known as a "performance site" IRB approval. The University of Michigan’s IRB Performance Site IRB Application Example can be used as a model for your institution-specific "performance site" IRB application. Additionally, both the IRB Approval Letters for the Coordinating and Performance Site are located in our Downloads section.

If your site does not have an local IRB then MPOG can oversee the IRB at your institution. If you have any questions about the IRB process or need IRB oversight, please contact mpog-admin@med.umich.edu for more information.

Step 5: Review, Sign and Submit MPOG Bylaws

Can occur concurrently with Steps 1 - 8, required for a site to be active

All sites must review, sign and returned the MPOG Bylaws which are the membership terms for participation. They must be signed by the department chair / head of practice and the anesthesiology PI or quality champion from your site. Once they are signed, return them to Tory Lacca.

Step 6: Obtain Server for Local MPOG Data

Can be done concurrently with Steps 1 - 5

The first step in MPOG implementation is to obtain a local server that will house your local MPOG data. This must be a separate server and can be a stand alone or virtual server, see the Server Requirements document in our Downloads section.

Please note, a site may purchase the server before the BAA is completed. The MPOG developers may assist with setting up the servers but cannot move forward with any of the technical build until the BAA is complete.

Step 7: Develop and Configure Data Interface to Transfer Data

Dependent on Steps 1, 2 and 6

After you have obtained a server and have a BAA in place, your site can start the data configuration. Depending on your institution’s anesthesia information management system (AIMS), your institution or department may need to develop and/or configure the data interfaces necessary to transfer your institution’s data to the central MPOG database.

MPOG has already developed configurable data interfaces for several AIMS systems including:

Centricity

Cerner

Epic

Your institution will need to configure the data interface to manage its institution-specific AIMS content. If your institution uses an AIMS that has data interface capabilities already developed by MPOG (see list above), the technical effort required to contribute data to MPOG is markedly reduced. If your institution uses an AIMS that does not have an existing MPOG data interface, your institution will have to develop the data interface and content mapping routines, which will require significant more work for your institution.

For Hospitals using Epic, the MPOG users guide is located in the Epic UserWeb on Galaxy, see your Epic TS for details. If your hospital uses any other AIMS, the MPOG Import Manager Playbook, Generic that guides prospective institutions through the setup of MPOG is located in the Downloads section of the website.

Additionally, there are data elements that are located outside the AIMS system, such as laboratory values, demographic, preoperative and postoperative, mortality or professional fee data. See the minimum data requirements page for the list of data elements required.

Please note, although MPOG staff can provide technical consultation for implementing MPOG they cannot be the primary developers for MPOG implementation.

Step 8: Submit Limited Dataset to Central MPOG Database

Dependent on Steps 1 - 7

Once the data from your institution’s AIMS, institutional data sources, and surgical outcome registries are extracted into your local MPOG database, they are almost ready for submission to the central MPOG database. MPOG provides utilities to help automate the following:

PHI Scrubbing: Although patient identifiers are used at your institution to aggregate data across disparate data sources, these identifiers are NOT sent to the central MPOG database. Prior to their removal, they are converted into hashed identifiers in accordance with the National Security Agency’s Secure Hashing Algorithm-256 (SHA-256). This hashing process eliminates the ability to re-identify the patient once the data is sent to the central MPOG database. The MPOG Application Suite will also remove all protected health information (PHI) other than date of service / surgery prior to data transfer. This includes name, date of birth, address, social security number, etc. For a complete list, please refer to HIPAA’s official PHI elements list. In addition, the suite will remove all public provider identifiers such as doctor name, doctor number (i.e. NPI), pager number, etc. However, all AIMS-generated system identifiers that are not publicly visible can and should be transmitted.